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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700583
Report Date: 06/11/2020
Date Signed: 06/11/2020 11:36:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CHATEAU ON CAPITOL AVENUE, THEFACILITY NUMBER:
342700583
ADMINISTRATOR:TYLER BARNESFACILITY TYPE:
740
ADDRESS:2701 CAPITOL AVENUETELEPHONE:
(916) 447-4444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY:81CENSUS: 50DATE:
06/11/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jill Whithim, NurseTIME COMPLETED:
11:40 AM
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Licensing program Analyst (LPA) Bethany Huusfeldt and Michael hood spoke to Nurse Jill Whithim over the phone. This visit was conducted via telephone due to COVID-19 and precautionary measures.

CCL received an incident report regarding an incident that occurred on 6/8/2020. R1 reported a fall in the past to staff, and R1 was in pain. R1 was sent out to the hospital and was found to have a rib fracture. Resident returned to the facility with medications.

At this time no deficiencies were cited.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany HuusfeldtTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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